Navigating the Health Care System

Advice Columns from Dr. Carolyn Clancy

Former AHRQ Director Carolyn Clancy, M.D., prepared brief, easy-to-understand advice columns for consumers to help navigate the health care system. They address important issues such as how to recognize high-quality health care, how to be an informed health care consumer, and how to choose a hospital, doctor, and health plan.

Deciding whether to go to the hospital emergency room (ER) is often a clear-cut decision. For instance, if you thought you were having a heart attack or realized that your child just swallowed a bottle of medicine, you would go to the closest hospital as quickly as you could.

Many other situations aren't as clear. Should you go to the ER if you have a high fever but can't get an appointment to see your doctor right away? Does a twisted ankle need attention tonight or can it wait until your doctor's office opens in the morning? Most ER visits take place after regular business hours (8 a.m. to 5 p.m.). That's when 63 percent of adults and 73 percent of children younger than 15 arrive for treatment, according to the Centers for Disease Control and Prevention.

Deciding whether your situation is a true emergency can be a tough call when you feel sick or are in pain. To help you decide what to do, you can call your doctor's emergency phone number and ask for advice. Some health plans offer advice from nurses over the phone that can help you make decisions about your care. These call lines can be helpful and are often available on a 24/7 basis.

It's a good idea to find out how your health plan defines an emergency. Some plans require you to call your primary care doctor before you go to the ER, unless your condition is life threatening. If you don't follow this policy, you could end up paying for the entire visit.

But don't worry that you'll have to foot the ER bill if you thought your condition or injury put your life at risk. Most States have enacted laws that forbid health plans from denying payment for ER care if patients believed they had life-threatening health conditions. Similar laws apply to people covered by Medicare, Medicaid, and other Federal health insurance programs. A major study found that these laws did not cause people to use the ER more often.

If you have a medical emergency and go to the ER, you should notify your health plan as soon as possible about that visit. If you are admitted to the hospital from the ER, you could be transferred to another hospital if the one you went to is not part of your health plan's network. This is another good reason to find out about your health plan's policies before you face a medical emergency.

Depending on where you live, you may have seen or used urgent care or retail medical clinics. These are often located close to hospitals or doctor's offices or inside some drug or large discount stores. Many health plans have added these clinics to their networks.

Although urgent care or retail clinics are not able to take care of emergencies, they are staffed to handle conditions that require fast medical attention, such as sore throats with fever and ear infections. And, if you have a real emergency, the urgent care center will help you get to an ER for the care you need. If you can't decide if you need urgent care, call your doctor's office and ask for advice.

As much as I wish everyone had health coverage and a primary care doctor, I know that's not the case. Many of the 47 million Americans without health insurance use ERs as their only source of health care. And some people who have health coverage but don't have a regular primary care doctor do the same.

In fact, a 2005 report from my Agency found that children from poor families were almost twice as likely as kids from higher-income families to use hospital ERs. Our report also found that most children used ERs for non-emergency problems, such as asthma, bronchitis, cuts, bruises, and sprains. Medicaid, the health insurance plan for low-income Americans, pays far more for care provided in an ER than it does for care given in a doctor's office.

Besides the higher cost, an ER visit usually isn't recorded in a patient's medical record. That's why I advise patients who use ERs or urgent care clinics for primary care to create a personal health record. This can be a simple folder or binder that includes medication lists, lab results, and treatment records. Having these documents in one place can reduce the chance that important information about your medical history will be overlooked.

ERs can literally save your life when you face a medical crisis. Use them wisely so they can continue to serve this function.

I'm Dr. Carolyn Clancy, and that's my advice on how to navigate the health care system.

 

More Information

AHRQ Podcast
Navigating the ER—Using Urgent and Emergency Care  (Transcript)

Agency for Healthcare Research and Quality
Questions and Answers About Health Insurance: A Consumer Guide
http://www.ahrq.gov/consumer/insuranceqa/

Agency for Healthcare Research and Quality
Healthcare Cost and Utilization Project
AHRQ News and Numbers: Hospital Emergency Departments Treat Mostly Poor Children
May 22, 2008
http://www.ahrq.gov/news/nn/nn052208.htm

Centers for Disease Control and Prevention
Americans Made Over 1 Billion Hospital and Doctor Visits in 2006
August 6, 2008
http://www.cdc.gov/media/pressrel/2008/r080806.htm

Annals of Emergency Medicine
The Impact and Enforcement of Prudent Layperson Laws
May 2004
http://www.ncbi.nlm.nih.gov/pubmed/15111914

Current as of August 2008
Internet Citation: How To Use Hospital Emergency Rooms Wisely. August 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/columns/navigating-the-health-care-system/081908.html